SERENITY🍂 Asistencia Funeraria para la Familia y Mascotas

Holder & Co-Holder Info

Holder information

First Name

Middle Name

Last Name

Birthdate

Age

Birth Country

Gender

Marital Status

Language

Address

City

State

Address Street 2

Zip Code

Country

Phone

Other Phone

Beneficiary

Co-Holder Information

First Name

Middle Name

Last Name

Phone

Business Phone

Address

City

State

Address Street 2

Zip Code

Country

Beneficiary

Plan & Beneficiaries

RAÍCES PLAN

(6 beneficiaries)

$299

RAÍCES PLUS PLAN

(6 beneficiaries)

$499

RAÍCES EURO PLAN

(6 beneficiaries)

(España+Latam)

$699

RAÍCES EURO PLUS PLAN

(6 beneficiaries)

(España+Latam)

$799

RAÍCES GLOBAL $3000 PLAN

(6 beneficiaries)

(Mundial)

$599

RAÍCES GLOBAL $5000 PLAN

(6 beneficiaries)

(Mundial)

$899

RAÍCES GLOBAL $7000 PLAN

(6 beneficiaries)

(Mundial)

$1100

Please List of beneficiaries

1

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

2

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

3

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

4

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

5

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

6

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

Medical Questions

Has any of the beneficiaries been diagnosed with a terminal illness or suffers from an illness that may provoke an imminent death? (including covid-19)

Yes

Are any of the beneficiaries currently hospitalized or in a hospice? (nursing home)

Yes

Does any of the beneficiaries suffer or had suffered or has been diagnosed from any of the following illnesses or medical conditions? Cancer in remission within the past 5 years, renal insufficiency, dialysis, stroke, cardiovascular accident, arteriosclerosis, or organ transplant in the past 3 years, or any other medical condition in which a medical professional has diagnosed you with a terminal illness, or any other condition that may provoke the imminent death of the beneficiary in the next 18 months.

Yes

Share 1	Price	Payment Date
Share 2	Price	Payment Date
Share 3	Price	Payment Date

Holder & Co-Holder Info

Holder information

Co-Holder Information

Plan & Beneficiaries

1

2

3

4

5

6

Payment

Instrucciones para pagos por ZELLE.

Medical Questions